Pay for Preceptors

Pay for Preceptors - A Changing Scenario

Just got back from a consultation with Florida State regarding their new medical school. One of the biggest debates was about paying preceptors to teach. Florida state has trained first year medical students for years but will be adding years 2-4 soon and will be promising to graduate more into geriatrics, primary care, rural locations, the care of minorities, and the underserved. They are building a clinical teaching network from scratch without an academic medical center.

I gave some of the usual arguments against this practice as per the experience of North Carolina and other states ( See preceptor pay, older version ). I was feeling pretty good, and then talked to my chair. He mentioned that preceptor pay is now an issue for us in the next years. It seems that the University people wanted a tax of $500 per ticket to allow volunteer preceptors to continue to have the priviledge of buying tickets to Nebraska football games. This has been a major benefit that has made retention of the experienced preceptors much less of a problem. The next year will be interesting in more than just football rankings.

States who have continued long traditions of preceptors (Wisconsin, Nebraska, Minnesota, others) may have less trouble convincing former preceptees to become preceptors. Other states lost their preceptorship. Still some, like Florida State, are starting from scratch. The assistance of the state academy has been helpful in keeping preceptorships going when the curriculum committees carved out preceptorships a few decades ago.

Some arguments for total volunteer preceptors:

Preceptors should be expected to teach, by Hippocratic Oath.
Preceptors expected to teach, because they were students and when they were students someone taught them for free, especially in states like Nebraska with a 50 year tradition of teaching all students across the state.
Paid preceptors might not be the best preceptors (blood bank volunteer argument). There are inconsistent preceptors, some teach better than others (not just shadowing, actually look at objectives, part of their nature). Doing it for pay introduces other variables

Studies consistently show that preceptorship students take an additional hour a day to teach. Interviews with preceptors and those who work with them show that additional time comes out of family time, practice management time, socializing with health care and working in other areas, such as with community people, etc.

Problems with paying preceptors

IRS and state taxing bodies get 30 - 50% so a great deal of the money paid is immediately lost.
Compared to overall income and especially lost income, whatever paid is not enough.
Loss of volunteer preceptor status where such benefits exist.
Whenever money is discussed, someone will argue the last penny.
Some preceptors spend more time than others.
It is impossible to pay preceptors equitably based on numbers of learners.
It is hard to adjust pay and effort based on variation in contributions of learners, students vs experienced residents.

How Students Can Contribute To Rural and Underserved Practices

Community projects to benefit practice, hospital or community
Educational impact on the preceptor
Support for providers, feeling of accomplishment of provider
Assistance with patient care (students can gather information and screen patients and assist with more routine tasks)
Longer term students and those with more experience can contribute to patient care. Students now have much more experience in the early years. Patients do get something out of encounters with students. Some students enter school older and more mature. Some students have volunteered even more hours or have experiences of great value to preceptors (mental health, AIDS phone volunteer, pharmacist in past, just to mention a few).

Point to Ponder

Why not find someone (a corporate sponsor foundation) to donate to pay for football tickets, rural expert assistance, computer equipment, software, management consultants, CME, etc.?

Focus groups identifying and expanding on the needs of a group of preceptors might help identify other areas of mutual benefit.

Better documentation systems (dictation, templates, coding reminders, training, software)
Practice management (could do practice billing but also collect data on preventive, do reminders, track target patients at risk, do population based studies)
Continuing education - especially on line while doing patient care, or CME credits to be used
Information system updates - software or hardware
Computer training
Better reimbursements
Linkages to larger systems of care - rural health experts
Specialists to come to towns to do care
Faculty to visit
Recognition
Better time management
More time to visit with colleagues and plan locally

Again looking at the personal touch, preceptors might be impressed if they just found out what happened to those that they precepted, or just receiving a card from them. For memory purposes, we could add a list of names of preceptees under the plaque. (A good use of our new tracking data base.) If we plan to rely mainly on the Hippocratic Oath duty to teach, we better improve our efforts in other areas!

My solution to the community preceptor pay issue is not to pay, but to make sure that the students or residents contribute in other ways. Some go to communities and give the community valuable information. Others who see patients could stay longer - long enough to learn the system and contribute to the care of patients.

Jack Verby, former director of the RPAP program in Minnesota, told me that practices with RPAP students (nine months rural preceptorship in the third year), billed $40-70,000 more during the time that an RPAP student was there. During that time period many of the students were at their rural sites for up to a full year. Obviously the point is not the income that can be generated, but the quality of care, the support, and the assistance give to help practitioners who do lots of care.

Similarly residents can contribute positively to the practice finances in a few months (have some data and mostly anecdotal info), not to mention the much appreciated help with the call schedule. We do require the hospitals to pay us the resident stipend, local housing, and one round trip and they continue to support this, although more likely for the potential to recruit a resident. We also send them a new resident every two months for three years and this tends to create a pool of patients and allows them to adapt the clinic to the residents. See Nebraska Graduate Programs

We are obviously limited by the RRC to a two month rotation, but even more help could come from 3 or 4 months at a rural site or a repeat 1-2 month visit to the same site later.

The fact that our residents rotate rural in sites short of physicians may be a major reason for this contribution. Studies of locums show that local patients will bypass the temp docs to get to the regular ones. One month rural rotations, although helpful educationally and improving the choice of rural practice from 36.5% of residents to 45.6%, are just not as good for the practice sites and physicians. Longer would be better for the practice and could increase the choice of rural practice.

Programs with 0 months rural rotations graduate 24.4% into rural practice 1 month 36.5% 2 months 45.6% 3 months 52.3% 4-6 51.4% 18+ 68.5% (program or RTT in rural area) 1992-94 program grads n=326 88% response The issue of preceptor pay will not go away, especially as doctors continue to become employees more and more.

Recruitment of Rural Preceptors

The major issue behind the recruitment and retention of rural preceptors seems to be the importance of site visits. Many programs and medical schools use the phone and mail or convenient meetings and wonder why they have a poor response. Programs who recruit and retain with site visitors to rural practices seem to have more success. Rural folks appreciate a personal touch. For years the top requested rewards in surveys of our preceptors have been Nebraska football tickets (many years back), CME opportunities, and bookstore discounts (many already have computer access to UNMC). The only thing we did give them was a plaque and some recognition.

We also moved the student preceptorship two months to the third year instead of the fourth and we added a three week M-1 rotation and now we are pressuring them to give more realistic evaluations. For years we have tried to convince UNMC to offer CME program access as some token recognition of a job well done. Recently Creighton did so ($300 a year toward programs at Creighton) and we will finally follow suit, having lost the initiative.